REVRAT

Maryam Sidika Ogmun 1713010019

Faqih Faris Naqi 1713010032
Title and abstract
1. Title :
The Effect of Ethiopia’s Community-Based Health
Insurance Scheme on Revenues and Quality of Care
Abstract :
The author find that CBHI-affiliated facilities experience
a 111% increase in annual outpatient visits and annual
revenues increase by 47%. Increased revenues are
used to ameliorate drug shortages. These increases
have translated into enhanced patient satisfaction.
Patient satisfaction increased by 11 percentage points.
Background
2. Explain the scientific background and rationale for the
investigation being reported

In June 2011, motivated by the limited increase in health

care utilization, despite substantial supply-side
investments in the country’s health care infrastructure, the
Ethiopian Government introduced a pilot voluntary
Community-Based Health Insurance ( CBHI ). Based on a
systematic review of 46 CBHI studies conducted in low-
and middle-income countries, reports an unweighted
average insurance uptake rate of 37% and high dropout
rates.
3. State specific objectives, including any prespecified
hypotheses
The main objectives of the paper are to examine the effffect
of being a CBHI-affiffiffiliated health center on the volume of
patients accessing health care services, followed by an
assessment of the scheme on resource mobilization and on
two types of quality measures—perception-based measures
and indicators of structural quality.
Methods

4 .Present key elements of study design early

in the paper
We assessed the effect of being affiliated to
the CBHI on these outcomes using
difference-in-differences approach. That is,
we exploited the longitudinal nature of the
data and estimated a health facility model
which contains both fixed and temporal
components.
5. Describe the setting, locations, and relevant
dates, including periods of recruitment,
exposure, follow-up, and data collection
Setting : Ethiopia
Dates for research : 2011 until 2014
Data collection : review from 36 study for
quality care, take the data administrative from
medical facility, survey house hold data from
medical facility
Participant

6 (a) Cross-sectional study—Give the eligibility

criteria, and the sources and methods of
selection of participants.
48 health centers, 3 in each of the 16
districts. Of these 16 districts, 12 are
districts where the CBHI was offered and
four are districts where it was not offered.
Variable

7. Clearly define all outcomes, exposures, predictors, potential confounders,

and effect modifiers. Give diagnostic criteria, if applicable
1. Conceptualizing Quality of Care
Structure refers to the availability of physical facilities, equipment, drugs and
human resources.
2. The Effects of CBHI on Revenue Generation and Quality of Care
In a review of 36 studies, The study concludes that such schemes have
moderate effffects on cost-recovery (cost-recovery ratio of 25%) and no
evidence that they have an effffect on quality of care.
3. Health Care Financing in Ethiopia and the CBHI: A Brief Overview
the CBHI scheme had received about ETB 30 million as membership
contributions. Additionally, according to utilization of health care rose by at
least 30% and the frequency of visits by at least 45%.
8. For each variable of interest, give sources of data
and details of methods of assessment
(measurement). Describe comparability of
assessment methods if there is more than one
group.

The authors take the data sources from review

from 36 study for quality care, take the data
administrative from medical facility, survey house
hold data from medical facility.
Bias

9. Describe any efforts to address potential sources

of bias
The authors used a difference-in-differences
approach applied to two rounds of health facility
survey data and three rounds of household
survey data to examine the effect of a CBHI
scheme introduced in Ethiopia. So, it will be avoid
the bias because each variable use the different
method.
Study Size

10. Explain how the study size was

arrived at
The study size was arrived when the all
data was collected
Quantitative Variables
11. Explain how quantitative variables were handled in
the analyses. If applicable, describe which
groupings were chosen and why
The quantitative variables were handled using
formula yjt = α + βCBHIj x d2014t + Xjtδ + πd2014t
+ θj + εjt
Statistical Method
12 . Describe all statistical methods, including those used to control for
confounding.
The statistical methode using Descriptive Statistics for Effect of CBHI
Affiliation on Patient Volume and Revenues, Effect of CBHI Affiliation on
Quality of Care, . Effects of signing CBHI contract on availability of
drugs, medical equipment/facilities and basic infrastructure.
(b) Describe any methods used to examine subgroups and interactions
Not described in this article
(c) Explain how missing data were addressed
Not described in this article
(d) Cross-sectional study—If applicable, describe analytical methods
taking account of sampling strategy
This article using descriptive statistics for the research
Participants
13. (a) Report numbers of individuals at each stage of study—eg
numbers potentially eligible, examined for eligibility, confirmed
eligible, included in the study, completing follow-up, and analysed

The first health facility survey, a baseline round was conducted in

2011 and a second follow-up survey, after the introduction of the
CBHI, was conducted in 2014. In both years, the surveys gathered
information on 48 health centers, 3 in each of the 16 districts. Of
these 16 districts, 12 are districts where the CBHI was offered and
four are districts where it was not offered. On average, in 2010–
2011, there were about 3.3 health centers per district (nationwide)
[36]. This number was calculated dividing the total number of
health centers (2660) by the total number of districts (800) in the
country in 2010–2011 [36]. Thus, our surveys cover almost all the
health centers in these 16 districts.
Descriptive data
14. (a) Give characteristics of study participants (eg demographic,
clinical, social) and information on exposures and potential
confounders

Of the 48 health centers, 36 have signed contracts with

the CBHI scheme. Descriptive statistics of the variables
of interest in 2011 and 2014 are provided in Table 3.
Prior to the introduction of the CBHI, contracted health
centers recorded 590 patient visits per month per health
center in the 12 months preceding the survey while for
non-contracted centers the corresponding number was
a little higher at 637 visits per month.
 In 2014, patient visits to contracted centers almost doubled to
1073 visits per month while for non-contracted centers there
was almost no change (616 visits per month). Consistent with
this increase, there was a sharp jump in revenues from patient
cards, diagnoses, drug sales and total revenues at contracted
health centers.
(b) Indicate number of participants with missing
data for each variable of interest
not describe in this article
(c) Cohort study—Summarise follow-up time
(eg, average and total amount)
Not describe in this article
Main results
16. (a) Give unadjusted estimates and, if applicable,
confounder-adjusted estimates and their precision (eg,
95% confidence interval). Make clear which confounders
were adjusted for and why they were included

CBHI-affiliated facilities experience a 111% increase in

annual outpatient visits and annual revenues increase
by 47%. Increased revenues are used to ameliorate
drug shortages. These increases have translated into
enhanced patient satisfaction. Patient satisfaction
increased by 11 percentage points.
 Despite the increase in patient volume,
there is no discernible increase in waiting
time to see medical professionals. These
results and the relatively high levels of CBHI
enrollment suggest that the Ethiopian CBHI
has been able to successfully negotiate the
main stumbling block—that is, the poor
quality of care—which has plagued similar
CBHI schemes in Sub-Saharan Africa.
(b) Report category boundaries when continuous
variables were categorized
1. Effect of CBHI Affiliation on Patient Volume and
Revenues
The increase amounts to 653 more outpatient visits per
month or an increase of 111%, as compared to
outpatient visits to contracted health centers in 2011.
As compared to the baseline for the contracted group,
signing a contract is associated with a 178% increase
in revenues from patient cards and a 75% increase in
revenues from drug sales.
 Effect of CBHI Affiliation on Quality of
Care
Table 5 provides information on the
manner in which CBHI-generated
resources are spent. The most
common use is to purchase drugs and
disposable medical equipment such as
syringes, gloves and other related
items.
(c) If relevant, consider translating
estimates of relative risk into absolute
risk for a meaningful time period
Not describe in this article
Other analyses

17. Report other analyses done—eg

analyses of subgroups and
interactions, and sensitivity analyses
Not describes in this article
Discussion
18. Summarise key results with reference to study
objectives
This paper examined the effect of health facility affiliation
to a CBHI scheme in Ethiopia on the volume of
outpatient visits, resource mobilization and quality of
health care. The paper was based on a two-round panel
of 48 health facilities and three rounds of household
data. Consistent with [35], we find a sharp increase
(111%) in the number of outpatient visits to CBHI-
affiliated health centers.
 The increase in patient flows was accompanied by
increases in health center revenues of 47%. As part of a
virtuous cycle, the increased revenue flow was
predominantly used by health centers to purchase drugs
and disposable and durable medical equipment. We also
found a positive effect on patient satisfaction. Patients
treated at CBHI-affiliated health centers were 11
percentage points more satisfied than those treated
elsewhere.
Limitations
19. Discuss limitations of the study, taking into account
sources of potential bias or imprecision. Discuss
both direction and magnitude of any potential bias

While these results are promising, they are based on a relatively

small sample and on data that were collected in 2011 and 2014.
This is a limitation of the current study and an update on the
basis of larger and more recent data is needed. To emphasize,
the data we do have covers almost all the health facilities in the
districts that were included in the CBHI household survey, and
offer sufficient variation across facilities and over time to identify
the effects of the CBHI scheme.
 However, the relatively small number of
observations reduces the statistical power of our
estimates. Nevertheless, the paper contributes to
the literature by examining the effects of such
schemes on outcomes that have not been
examined as often—most importantly, quality of
care, which has been identified as the key reason
for the lack of success of such schemes
Conclusions
20. Give a cautious overall interpretation of results considering objectives,
limitations, multiplicity of analyses, results from similar studies, and other
relevant evidence

The main conclusions are that the scheme is associated with an increase in
care utilization, an increase in revenue generation and an increase in patient
satisfaction. Despite the small sample size and limited statistical power,
these results and the relatively high levels of CBHI enrollment do support
the idea that the Ethiopian CBHI has been able to successfully deal with the
main stumbling block, that is, the poor quality of care, which has plagued
similar voluntary health insurance schemes in Sub-Saharan Africa. The
results of this paper along with the existing work on the Ethiopian CBHI
suggest that, as in the case of Rwanda and Ghana, the Ethiopian CBHI may
play an important role in enhancing access to health care to wide swathes of
the country’s population.
Generalisability
21. Discuss the generalisability (external validity) of
the study results
Not describe in this article
Funding
22. Give the source of funding and the role of the
funders for the present study and, if applicable, for
the original study on which the present article is
based
Funding: This research was funded by the Netherlands
Organization for Scientific Research (NWO-WOTRO), grant
number W07.45.103.00.